Permit 11 " CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2011 -00104
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/14/2011
Parcel: 2S 112 DD00300
Jurisdiction: Tigard
Site address: 15900 SW 72ND AVE
Project: Pacific Convenience & Fuels Subdivision: Lot: 0
Project Description: .3 EDU increase
Contractor: Owner: PACIFIC CONVENIENCE & FUELS
2603 CAMINO RAMON STE 350
SAN RAMON, CA 94583
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 07/14/2011 $1,350.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: 4
Number of Dwelling Units: .3
Total $1,350.00
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952- 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: /
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Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 2S112DD00300
Tenant Name: Pacific. Convenience & Fuels This SWR# SWR2011 =00104
Site Address: 15900 SW 72nd Ave. This PLM# PLM2011 - 00222
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery /Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 2 4 2 4
-3inch 5 0 0 0 0 0
- 4inch 6 0 0 0 0 0
Car Wash .Dm 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 - 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial,( over 5 HP) 42 • 0 0 0 0 • 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 • 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 • 0 0 0 0 0
Swimming Pool Filter 1 - 0 0 0 0 0
Washer - Clothes 6 ` 0 0 0 0 0
• Water Extractor • 6 - 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 _ 4 2 4
Current Fixture Value 4 divided by 16 = 0.3 Current EDU 1 EDU = $ 4,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 1,350.00
Enter EDU Change Here 0.3
Notes:
Authorized Name /Signature: Dianna Howse . • Date: 7/13/2011
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: ABuilding \Sewer Tally \ SewerTallySheet-4500.xls 07/01/11